Factors associated with under-five mortality in Rwanda: An analysis of the Rwanda Demographic and Health Survey 2020

Despite global and Rwandan progress in reducing under-five mortality, the risk of children dying before their fifth birthday persists, necessitating intensified research on determinants. Thus, this study analyzed the birth history data to shed light on the underlying causes of under-five mortality in Rwanda. The study is a secondary analysis of data sourced from the 2020 Rwanda Demographic and Health Survey (RDHS) cross-sectional design. Using SPSS, the data was cleaned, recoded, and weighted, with descriptive and inferential statistics applied. The dependent variable was the child’s living status, while independent variables included socio-demographic, media exposure status of mothers, child, and environmental factors. A total of 10267 under-five children of all interviewed mothers were included in the final analysis, of which 12.3% (1260) died. Maternal age (25–34 years: AOR = 1.514, 95% CI = 1.130–2.029, p = 0.005; 45+: AOR = 13.226, 95% CI = 9.253–18.905, p<0.001), occupational status (agricultural workers and other services), and three or more births within five years (AOR = 1.895, 95% CI = 1.433–2.508, p<0.001) significantly increase the risk of under-five mortality. Conversely, maternal education (primary: AOR = 0.821, p = 0.023; secondary: AOR = 0.533, p<0.001; higher: AOR = 0.365, p = 0.010) and higher wealth indexes (middle: AOR = 0.743, p = 0.001; rich: AOR = 0.612, p<0.001), as well as current breastfeeding (AOR = 0.524, 95% CI = 0.455–0.603, p-value <0.001), are associated with lower under-five mortality. Child sex significantly impacts under-five mortality (AOR = 0.873, 95% CI = 0.770–0.991, p = 0.035), favoring females over males. Conversely, multiple birth type children face higher under-five mortality (AOR = 3.541, 95% CI = 2.727–4.599, p<0.001) compared to singletons. Children in the northern (AOR = 1.478, 95% CI = 1.086–2.011, p = 0.013) and eastern (AOR = 1.470, 95% CI = 1.097–1.971, p = 0.010) regions are more susceptible to mortality compared to those in the central (Kigali) region. Additionally, under-five mortality is higher when using water from tanks and other sources (AOR = 2.240, 95% CI = 1.471–3.411, p<0.001) than piped water. This study identifies crucial factors linked to under-five mortality, underscoring the importance of prioritizing them in interventions to enhance Rwandan under-five survival rates.


Introduction
Under-five mortality remains a critical lens through which the health landscape of a nation and its population is evaluated [1].The World Health Organization (WHO) defines under-five mortality as the overall number of child deaths occurring within the initial five years of life for every 1000 live births [2].While there has been significant global progress, the mortality rate has decreased by almost 60% over the past 30 years [3].It remains a major burden in sub-Saharan Africa and South Asia.In 2020, over 80% of the 5 million under-five deaths occurred in these regions, with sub-Saharan Africa contributing the highest number (2.8 million) [3,4].This concerning concentration of under-five mortality is further highlighted by the fact that the global rate stagnated at 5 million deaths in 2021, with a significant proportion attributed to preventable or treatable conditions, malnutrition, and various socioeconomic challenges [5,6].Moreover, many researches have provided insights into the mother, child, and socio-demographic factors contributing to under-five mortality in sub-Saharan African countries (SSA) [7,8].Most of these factors were linked to poverty and need to be investigated with a customized approach to eliminate each country's causes.
Rwanda, an SSA country striving to achieve middle-income status by 2035, has shown significant progress in addressing under-five mortality.Data compiled by the Inter-agency Group for Child Mortality Estimation (UNICEF, the World Health Organization, United Nations, and World Bank) reveals a remarkable decline in the Rwanda under-five mortality rate, dropping from approximately 341 in 1994 to about 40 children in 2021 [9].This translates to a 70% decline between 2000 and 2011, positioning Rwanda among the leading low-income countries in SSA on track to achieve MDG4 by 2015 [10,11].This positive trend can be attributed to various health initiatives that improved geographic access by increasing the number of primary healthcare facilities, reducing financial barriers, and implementing community-based health insurance [12,13].Noteworthy collaborations, such as the Rwanda government's partnership with health organizations to establish the White Ribbon Alliance (WRA), have been instrumental.The WRA is dedicated to reducing maternal and newborn mortality rates, with a significant focus on ensuring the well-being of children up to their fifth birthday [14].However, to achieve the 2030 Sustainable Development Goals (SDGs), Rwanda must intensify efforts to enact efficacious strategies addressing inequities and decreasing death rates among children under five [15][16][17][18].This could involve comprehensive research on the various determinants of under-five mortality, utilizing demographic and health surveys.The DHS data is a valuable resource for understanding various health indicators, as it is nationally representative and appropriate for determining factors associated with under-five mortality in countries where it is conducted.
The Demographic Health Survey utilizes the birth recode file to capture data on every child born to interviewed women, providing comprehensive estimates of under-five mortality for all children born to eligible women.This study employs the 2020 Rwanda Demographic Health Survey (RDHS.)Birth Recode dataset to identify factors associated with under-five mortality in Rwanda.Through thoroughly examiningthis dataset, we aim to unravel the complex web of socioeconomic, maternal, child-related, and environmental determinants influencing underfive mortality.The findings will inform recommendations to policymakers, non-governmental organizations (NGOs), and other stakeholders, facilitating the implementation of effective interventions to reduce nationwide under-five mortality rates.

Study setting
The study was conducted in Rwanda, a nation classified as a low-middle-income country with an estimated population of around 12 million individuals [19].Geographically, Rwanda is divided into five provinces: Central, East, West, North, and South, with each province further comprising districts.This decentralized administrative framework significantly contributes to Rwanda's achievements in enhancing maternal and child health (MCH) metrics.The Rwandan health system is organized into a tiered network of facilities, providing accessible care at various levels:

Health posts
These are located in villages and staffed by Community Health Workers (CHWs), offering essential maternal and child health (MCH) services such as antenatal care, postnatal care, childhood vaccinations, and family planning.A total network of 406 health posts plays a vital role in ensuring access to basic healthcare in rural areas [20].

Health centers
These are located in the in districts and provide a broader range of Maternal and Child Health (MCH) services.They are staffed by nurses, midwives, or clinical officers capable of managing complex deliveries and childhood illnesses and offering additional services.There are 495 health centers, forming the backbone of the health infrastructure, which heavily relies on a tiered network of primary healthcare facilities dedicated to MCH service delivery.

District hospitals
As the name suggests, they are located in the districts and serve as referral points for complicated cases requiring specialized care within the Rwandan health system.This structured approach ensures that Maternal and Child Health (MCH) services are geographically accessible to most Rwandans, particularly those in rural settings [21].However, despite its effectiveness, the system faces several challenges that can impede service delivery and contribute to child mortality.In total, the Rwandan health system comprises 8 national referral hospitals, 4 provincial-level hospitals, and 35 district-level hospitals.

Study design
This study conducts a secondary analysis of data from the 2020 Rwanda Demographic and Health Survey, a cross-sectional survey implemented every 5 years as part of the global Demographic and Health Surveys project to monitor and evaluate population, health, and nutrition programs".
The sample design was based on the 2012 Rwanda Population and Housing Census (RPHC) conducted by the National Institute of Statistics of Rwanda (NISR) [19].It is a crosssectional design that involves two-stage approaches to facilitate the estimation of key indicators at various levels, including national, urban, rural, provincial, and district.The first stage involved selecting 500 clusters from the 2012 RPHC enumeration areas (EAs), which comprised 112 urban and 388 rural areas.The second stage included the systematic selection of households from lists compiled during a household listing operation carried out in these chosen EAs between June and August 2019.A total of 13,000 households were included, with 26 households sampled from each cluster [19].Weighting factors were applied to the data to ensure representative results at the national level.

Source of data
Data was acquired by developing a concept note, enabling access to RDHS data via the Measure DHS program's website (www.measuredhs.com),which collects data in more than 90 countries, primarily in low-and middle-income nations.This collaborative initiative involved the National Institute of Statistics of Rwanda (NISR) and the Ministry of Health (MOH) to improve the health outcomes of Rwanda's population.The extensive survey collected demographic and health data from a nationally representative sample of women aged 15-49 [19].Data collection spanned from November 9, 2019, to July 20, 2020, with a temporary halt of over two months due to a nationwide lockdown in response to the COVID-19 pandemic.The BR file containing data about under-five children was used and is accessible at https:// dhsprogram.com/data/availabledatasets.cfm.

Sample size
The data included 10267 children within the age of five years ever born to an interviewed mother.Our analysis specifically included all births within the five years prior to the survey.We included all living children within five years of age and all instances of under-five mortality, excluding any deaths of children older than five years.

Dependent variable
The dependent variable in this study, originally coded as "Child's alive," was recoded to represent the child's living status for children between 0-59 months old.This variable was obtained based on the binary response of interviewed mothers about the survival status of their children under five.The binary response to the question (child's living status) was "No," which was coded as "0," and "Yes" coded as "1".Since the outcome of interest was death/mortality, the variables were transformed and recoded inversely.Thus, the final recoded values for child living status are as shown in Fig 1.

Independent variables
The independent variables were selected based on prior research that has shown an association between these factors and under-five mortality [22][23][24][25][26].They were categorized into sociodemographic characteristics, environmental, media exposure status of mothers, and child factors.Socio-demographic factors constitute marital status, breastfeeding, mothers' age, pregnancy status, number of childbirths in the past five years preceding the survey, the total number of children born, and educational level.Environmental factors were the residence region and the delivery place in a private or public facility.In contrast, the media exposure status of mothers includes the frequency of watching television, listening to the radio, reading newspapers/magazines, owning mobile phones, and using the internet.Finally, the child factors entail sex, birth size, and birth type.This categorization was based on the conceptual framework developed by Mosley and Chen for child survival in developing countries [27].

Data processing and statistical analysis
Data analysis was conducted using SPSS version 26 statistical software.The data was first cleaned recoded, and the weight (WGT) variable was generated (v005/1,000,000).The weight variable was applied throughout the analysis to consider the possibility of uneven sampling and guarantee that all strata were adequately represented.Moreover, multiple filters were applied to ensure that only death within five years was included in the final analysis since the birth recode file was used.Descriptive statistics were then employed, and frequency tables were generated to describe the proportions of all explanatory variables.Subsequently, inferential statistics was employed, and a Chi-square test was conducted to determine the association between the independent and the dependent variables.The binary logistic model included all variables that exhibited significant association at p-value <0.05.The univariate P-values, 95% confidence interval (CI), and crude odds ratio (COR) were displayed.The final logistic model included all independent variables associated with under-five mortality at P � 0.25.The results were displayed as adjusted odds ratios (AOR), confidence intervals (CI), and P-values.Independent variables that exhibited significance at p-value<0.05 of the final multivariable regression were used to explain the causes of under-five mortality.

Ethics statements and consent to participate
The data collection in the Rwanda Demographic and Health Survey (RDHS) was granted by the Institutional Review Board of the Rwandan Ministry of Health.Each participant voluntarily consented to the primary data collection of the RDHS.Our study obtained written permission to access the dat aset from MEASURE DHS, the organization tasked with overseeing demographic health surveys globally, and from the ICF Institutional Review Board.

Distribution characteristics and the factor associated with under-five mortality
A total of 10267 children within the age of five years whose mothers were interviewed were included in the final analysis.Of these, 12.3% (1260) of children were reported to have died below the age of five.The distribution characteristics are described as follows: A significant portion of mothers (47.2%) fall within the 25-34 age group and have primary education (65.8%).Most mothers (78.4%) lack bank accounts, while a substantial number work in agriculture (41.6%) or unskilled labor (24.1%).Media exposure is limited, with low rates of newspaper reading (18.3%),radio listening (76.0%),TV viewing (39.3%), and internet usage (9.1%).Children present a nearly even gender distribution (50.8% male, 49.2% female) with high health insurance coverage (79.6%), and more than half of them were being breastfed (62.4%).Geographically, the study population is predominantly rural (83.3%), with the highest density in the East region (27.1%) as exhibited in Table 1.

Factors associated with under-five mortality
Generally, all the distributive characteristics were significantly associated with under-five mortality at a significance of 0.05 (Table 2)

Determinants of under-five mortality in Rwanda
The correlates of under-five child mortality in Rwanda based on crude (unadjusted) and adjusted logistic regressions are presented in Table 3.Generally, the univariate logistic model

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exhibited significance for all the variables associated with under-five mortality at the Chisquare analysis.However, the final multivariable logistic model revealed that maternal age, educational attainment, occupational status, wealth index, current breastfeeding, number of births within five years, sex of the child, the type of birth, region, and source of the drinking water were significant determinants of under-five mortality of all births history of interviewed mothers and were presented below.

Maternal socio-demographic determinants
Most maternal socio-demographic factors were significant determinants of under-five mortality in Rwanda among all live births.Generally, maternal age, occupational status/type, and the number of births in the past five years by a mother were more likely to influence an increase in under-five mortality.Educational attainment, wealth index, and current breastfeeding of a child predicted a lower likelihood of a child dying below the age of five.Maternal age was a significant determinant of childhood mortality in Rwanda.Specifically, children born to mothers with higher age groups had a significantly higher chance of dying below the age of five compared to children born to younger mothers.In particular, children

Determinants of under-five mortality in Rwanda on the RDHS 2020 births recode data
The study investigates the determinants of under-five child mortality ever born to all interviewed mothers in Rwanda, thus shedding light on significant maternal socio-demographic factors (maternal age, educational attainment, maternal occupation, wealth index, breastfeeding status, number of births in five years), child factors (child's sex and type of birth), and geographical or environmental factors (region, and drinking water source).The media exposure status of mothers as a factor did not exhibit any significant influence on under-five mortality in Rwanda.These findings provide crucial insights into the multifaceted nature of all underfive mortality recorded by the 2020 RDHS birth history.

Maternal socio-demographic determinants
Maternal age.Maternal age emerged as a significant determinant of under-five mortality in Rwanda.Children born to older mothers face a higher risk of mortality, with a remarkable gradient in risk as maternal age increases.In particular, children born to mothers aged 35-44 and 45+ are 4.33 and 13.23 times substantially more likely to die before the age of five compared to those born to younger mothers, which is similar to findings in Ghana and Kenya [28,29].This outcome also aligns with studies from Sierra Leone and aggregated data from recent Demographic and Health Surveys in 30 Sub-Saharan African countries (2010-2019), underscoring the effect of maternal age on child survival [26,30].However, our data suggests a stronger association between maternal age and under-five mortality compared to Ghana, with AOR = 11.4 (age [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] [28,29].There could be different reasons for this finding, which may include the increased risk of pregnancy complications such as gestational diabetes, preeclampsia, and placental problems associated with advanced maternal age that can affect the health of both the mother and the child, potentially leading to adverse outcomes [31].It is important to note that age has been implicated in under-five mortality differently.For instance, Koroma et al. exhibited that younger mothers aged 15-19 (teen mothers) in Sierra Leone were more likely to lose their children below the age of five compared to old-age mothers.However, our study did not categorize teen mothers separately.
Moreover, the different ages in different countries have different influences based on cultural practices.Hence, age is a crucial determinant of under-five mortality.Implementing targeted health policies and awareness campaigns for the different maternal ages is vital for enhancing maternal and child health and improving under-five survivability.
Occupational status.Occupational status or the type of occupation undertaken by the mother also plays a significant role in under-five mortality.Children born to mothers engaged in agricultural work or employed in other services are respectively 1.30 and 1.41 times at an increased risk of under-five mortality, similar to an earlier study in Nigeria [32].However, the association between occupational status, such as agricultural work, and under-five mortality is less pronounced (OR = 1.30) in our study compared to Nigeria, where it is stronger (OR = 2.68) [32].The possible reason for the increased risk of under-five mortality among this occupational status group could be explained in terms of the possible insufficient focus on child caregiving by agricultural women and other service providers (sales and manual labor).For example, a study in Nigeria documented that these occupational categories exhibit the lowest rates of childhood vaccination coverage [33], which could make children vulnerable to preventable child diseases.Occupational status and child mortality have yielded mixed outcomes in earlier studies; Hence, occupational status or types should be greatly considered in health planning policies and strategies to target interventions for specific occupational groups to reduce child mortality rates.
Number of births in five years.Additionally, the number of births in five years by a mother is associated with an increase in under-five mortality.Children born to mothers with three or more births in this period face an elevated risk of mortality, similar to recent studies conducted in Sierra Leone and Ghana [26,34,35].However, our study exhibited a weaker (AOR = 1.90) association between three births in five years and under-five mortality compared to Sierra Leone (AOR = 8.11) for the same three births in five years [26,34,35].The elevated risk of child mortality with an increase in the number of births could stem from difficulties in providing sufficient care and attention to each child.For example, Khan et al. identify malnutrition, especially in children with low birth size, as a major factor contributing to child mortality [36].Inadequate care can result in poor or unbalanced nutrition, heightening susceptibility to diseases.Ensuring access to family planning services and maternal education for mothers with higher parity may increase childbirth spacing andchild survival.
Maternal education and wealth index.Maternal educational attainment and wealth index are other important determinants of under-five mortality exhibited in our study.Higher maternal education and belonging to the middle and rich wealth index were associated with lower under-five mortality.Children whose mothers have attained primary, secondary, or higher education are, respectively, 0.82, 0.53, and 0.37 times less likely to die before the age of five compared to children whose mothers did not receive formal education, as supported by recent findings in Sierra Leone, Nigeria, and Tanzania [37,38].Children born to mothers with primary educational attainment in our study had a significantly lower risk of under-five mortality (AOR = 0.82) compared to children born to Tanzania mothers with the same educational level attainment (AOR = 0.76) [37,38].Mothers with secondary education in Rwanda had a lower risk of under-five mortality for their children (AOR = 0.53) compared to Nigeria (AOR = 0.75).However, Tanzania showed an even greater protective effect (AOR = 0.30) for mothers with the same education level.Similarly, children born to mothers in the middle or rich wealth index categories are less likely to die under the age of five compared to those born to mothers categorized as poor [39].Our findings suggest that academic attainment and wealth index likely play a crucial role in influencing child health outcomes.Educated mothers may be better equipped to utilize resources, regardless of their income level.They might have increased health awareness, improved healthcare navigation skills, and a stronger voice in decision-making regarding their children's health.Additionally, wealth can provide access to vital resources such as nutritious food, sanitation facilities, and quality healthcare services, further improving child health prospects.This highlights the potentially synergistic effect of these factors.Mothers with both higher education and greater wealth might be particularly well-positioned to ensure the well-being of their children [37,38].This underscores the importance of investing in maternal education to reduce childhood mortality, improve household economic status, and enhance child survival rates.
Breastfeeding status.Current breastfeeding status was found to be a significant influencer of under-five mortality.Children who were currently breastfeeding were 0.52 times less likely to die under the age of five compared to those who were not breastfeeding, similar to that exhibited by an early study in Sierra Leone and Nigeria [26,40].However, the association of current breastfeeding demonstrated a slightly higher risk of under-five mortality in our study compared to that in Sierra Leone (AOR = 0.20) [37,38].There could be several reasons for this finding.Breast milk provides essential nutrients and antibodies that help strengthen a child's immune system, protecting against infections and diseases [41][42][43].
Additionally, breastfeeding promotes bonding between the mother and child and the emotional connection, which may positively affect the child's overall well-being.Access to clean water and proper sanitation, which are common challenges for formula feeding in some regions, might also play a role.It's a complex interplay of biological, environmental, and socioeconomic factors.This highlights the critical role of breastfeeding in child health and emphasizes the importance of promoting and supporting breastfeeding practices.
Media exposure status of mothers.Our study demonstrated that the media exposure status of mothers was significantly associated with under-five mortality in the univariate model.Yet, this association did not reach statistical significance in the multivariable model, contrasting with findings from another study [44].It suggests that while there may be individual associations between the media exposure status of mothers and under-five mortality when considered in isolation, these factors lose significance when analyzed with other variables.Possible implications could be that the influence of media exposure status of mothers as a factor on under-five mortality might be confounded or influenced by other variables included in the multivariable model.It could also indicate that the relationship is not as direct or substantial when accounting for other relevant factors.

Influences of child factors on under-five mortality
Sex and birth type.The analysis of child factors, specifically sex and birth type, were significant determinants of under-five mortality in Rwanda.These findings are similar to earlier studies conducted in Sierra Leone and Ethiopia using similar DHS [26,45].In particular, females exhibited a lower likelihood of under-five mortality compared to males, consistent with studies in Sierra Leone, Ethiopia, and Indonesia [26,44,46] and highlighting gender differentials in child health outcomes.The lower risk of female under-five mortality (AOR = 0.87) in our study was almost similar to that in Ethiopia (AOR = 0.84) [26,45] but was higher than that of Sierra Leone (AOR = 0.68) [26,45].
This finding could be attributed to complex and multifactorial reasons, such as biological, social, and cultural factors, behavioral differences, and environmental factors, which may vary depending on the specific context and population being studied.For instance, biologically, research suggests that the increased risk of male child mortality may be attributed to their XY chromosomes, which are more susceptible to X-linked recessive disorders than the XX chromosomes in females, resulting in poorer overall health outcomes for males compared to females [47,48].Our finding raises questions about potential gender-specific vulnerabilities or protective factors that should be further explored to inform targeted interventions.More importantly, healthcare professionals and policymakers should develop gender-sensitive interventions and public awareness campaigns to address gender-specific vulnerabilities contributing to under-five mortality in Rwanda.
Children born as multiples had a notably higher probability of not surviving past their fifth birthday than those born singletons.This finding is consistent with earlier studies in Sierra Leone and Ethiopia [26,45,49].Our study exhibited a stronger association (AOR = 1.41) between multiple births and under-five mortality compared to Sierra Leone (AOR = 1.41) [26,45].However, this association was observed to be weaker in Ethiopia (AOR = 4.755) [26,45].The increase in under-five mortality with multiple births could be attributed to factors such as higher rates of premature birth, lower birth weights, increased susceptibility to specific health conditions, and challenges in prenatal development, all of which are more common in multiple pregnancies and can impact the overall health and survival rates of these children [50].It could also be due to the sharing of limited resources, including food and care provided by the mother, among multiple children.The implications of this finding are crucial for maternal and child health programs, emphasizing the need for specialized care and attention for mothers carrying multiple pregnancies.

Geographical or environmental factors
Region and type of water source.Environmental factors exhibited a significant influence on under-five mortality at the univariate level.However, only the region and the type of water source exhibited significance in the multivariable analysis.Under-five children living in the north and east were more likely to die below the age of five compared to children in the central (Kigali).Similarly, under-five mortality was more likely to occur with drinking water from tanks and other sources compared to drinking piped water [51,52].However, drinking water from rivers, lakes, and ponds exhibited marginal significance.These findings align with other studies in Ethiopia that exhibit regional differences in under-five mortality [45,53].The higher under-five child mortality in the north and eastern regions compared to the central area (Kigali) could be attributed to disparities in healthcare access, infrastructure, and education, societal or cultural factors unique leading to differences in healthcare quality, living conditions, and levels of health awareness and practices among communities [54].Investigating regional under-five child mortality disparities will be necessary to understand the actual cause while conducting educational campaigns and data-driven interventions tailored to address specific challenges.
This study also exhibited drinking water from tanks and other sources to have a higher likelihood of under-five mortality than piped water, suggesting that the source of drinking water may significantly impact child mortality rates, similar to studies exhibited in Kenya and Ethiopia [51,52].Piped water often undergoes regulated treatment from the dam, ensuring higher quality and reduced contamination, thus explaining the lower mortality rates associated with this source.Tank water, on the other hand, even if treated, is often stagnant, which can often favor microorganism growth, and its contamination may impact the entire community drinking water from that source instead of a household.The marginal significance of mortality when drinking water from rivers, lakes, and ponds could imply a potential risk, albeit not as pronounced as tank or non-piped sources, likely due to varying degrees of contamination and treatment levels.Investing in enhanced water infrastructure and extending access to treated, piped water could substantially decrease under-five mortality [55] linked to potentially contaminated sources like tanks while enforcing stringent water treatment for non-piped sources like rivers, lakes, and ponds could mitigate associated risks.

Conclusion and recommendations
The analysis of determinants of under-five child mortality in Rwanda reveals significant associations with various maternal socio-demographic, child, and environmental factors.Maternal age, educational attainment, occupational status, wealth index, breastfeeding status, number of births, child's sex, birth type, region, and drinking water source emerged as crucial determinants impacting under-five mortality.Addressing these factors through targeted interventions could significantly improve child survival rates in Rwanda.While some factors like maternal age, maternal education, and breastfeeding show protective effects, others, such as occupation, birth numbers, and environmental factors, pose increased risks, highlighting the multifaceted nature of under-five mortality.
Strategically tailored health initiatives targeting specific maternal education levels, occupational challenges, and regions with higher under-five mortality rates are crucial.Strengthening maternal and child health services to support breastfeeding practices, providing healthcare services tailored to different maternal age groups, and empowering mothers in high-risk groups for better caregiving practices are essential.Investing in water infrastructure to extend access to treated, piped water, reducing reliance on potentially contaminated sources, and enforcing stringent water treatment for non-piped sources would mitigate associated risks.Conducting region-specific interventions addressing disparities in healthcare access, infrastructure, and education, along with gender-sensitive programs addressing vulnerabilities in male children, is vital.Additionally, providing specialized care and attention for mothers carrying multiple pregnancies would effectively reduce under-five mortality and enhance child well-being in Rwanda.

Strengths of the study
This study included a comprehensive approach, leveraging a substantial dataset of over 10,000 children under five years, enabling a multifaceted analysis of determinants influencing underfive mortality.This study used the birth recode data, which involved all birth histories of all interviewed mothers included in the study, and involved statistical rigor of multiple filters followed by association analysis and utilization of both univariate and multivariable analyses to enhance the reliability of the findings.Moreover, the study's relevance to policy and practice stands out, as its insights into maternal age, education, occupation, wealth index, and environmental factors directly inform potential interventions and policy development in maternal and child health in Rwanda.It also contributes to existing knowledge by affirming established associations and uncovering potential new determinants of under-five mortality.

Limitations of the study
Despite its strengths, this research faces limitations that are typical of similar studies.While it establishes associations between various factors and under-five mortality, it cannot definitively prove causation due to the nature of its design.Data collection might be affected by biases, including recall bias in maternal interviews, potentially impacting the accuracy of reported information.Additionally, the study might lack certain crucial variables that could significantly impact under-five mortality, such as specific health conditions, detailed access to healthcare facilities, or information regarding the quality of healthcare services.Addressing these limitations through more comprehensive data collection methods, including a broader array of variables, and a more nuanced study design would strengthen future research and deepen the understanding of under-five mortality in Rwanda and potentially in other similar contexts.